Participant flow
Study flow proceeded as described in Figure 1, with 112 survey responses (with 10 people providing combined responses about a main and satellite site: data from 122 physical sites total) from an initial potential 145 sites.
Participant characteristics
The site characteristics of survey participants are available in Table 1.
Table 1. Demographics of sites and participating sites
Regions
|
Total sites number
|
Responses number (%)
|
Australian Capital Territory
|
2
|
1 (50%)
|
New South Wales
|
37
|
26 (70%)
|
New Zealand
|
18
|
13 (72%)
|
Northern Territory
|
2
|
2 (100%)
|
Queensland
|
26
|
24 (92%)
|
South Australia
|
7
|
6 (86%)
|
Tasmania
|
2
|
2 (100%)
|
Victoria
|
26
|
25 (96%)
|
Western Australia
|
13
|
13 (100%)
|
|
|
|
Aust. Inst. of Health and Welfare, hospital classifications
|
(New Zealand)
|
18
|
13 (72%)
|
Private
|
13
|
12 (92%)
|
Large regional
|
21
|
20 (95%)
|
Medium regional
|
2
|
2 (100%)
|
Small/Medium regional
|
6
|
5 (83%)
|
Major
|
30
|
26 (87%)
|
Large metropolitan
|
27
|
24 (89%)
|
Medium metropolitan
|
10
|
8 (80%)
|
Specialist children's
|
6
|
2 (33%)
|
|
|
|
Age of patients
|
Adults and pediatric
|
121
|
105 (87%)
|
Adults
|
5
|
5 (100%)
|
Pediatric
|
7
|
2 (29%)
|
|
|
|
ACEM site classifications
|
Major referral
|
38
|
31 (82%)
|
Rural/regional base
|
45
|
38 (84%)
|
Urban District
|
50
|
43 (86%)
|
|
|
|
Hospital education accreditation time for each ACEM trainee/resident
|
6 months
|
37
|
32 (86%)
|
12 months
|
35
|
29 (83%)
|
18 months
|
19
|
12 (63%)
|
24 months
|
42
|
39 (93%)
|
|
|
|
Total
|
133
|
112
|
Overall, there was an 84% response rate; which was evenly spread across types of hospitals and regions. There was a lower response rate from specialist children’s hospitals, hospitals accredited for 18 months of training and a few states.
Sixty-six sites (59%) had appointed a head of research and 32 (29%) held the title of Director of Emergency Medicine Research or similar. All except 2 heads of research were Fellows of the Australasian College for Emergency Medicine (the others both hold a PhD). Amongst the heads of research, there were 12 Associate Professors and 8 Professors. We didn’t distinguish between adjunct/honorary and full university appointments. Forty-nine (74%) heads of research have a university affiliation, 28 (42%) have been a site chief investigator for a multisite project, 18 (27%) have been a principal investigator on a National Health and Medical Research Council grant. Forty-two university research degrees were awarded to 33 research heads (12 Doctoral degrees, 5 Doctors of Medicine, 13 Masters degrees and 12 other/unknown Higher Research Degrees). The levels of experience of heads of research are shown in Figure 2.
Types of research
Departmental research interests varied widely, reflecting the breadth of emergency medicine practice environments and populations (Figure 3). Ninety-six EDs contributed to multicentre research during the last 5 years. Fifty-two EDs contributed to ACEM CTN projects, mainly collecting data for the ARISE sepsis fluids observational study (n=52)(16) and the spontaneous pneumothorax study (n=19)(11).
Publications
Overall site contributions to publications were 3336 papers in the last five years from the 112 sites. This figure was calculated by summing the number of papers per site but there will have been overlap for multi-site investigations such that the true total number will be lower. Publication volume varied markedly. The 32 sites with a Director of Emergency Medicine Research (or equivalent) appointed published a median of 26.5 papers (n=1814; IQR 8,67; range 0,302). The 33 sites with a head of research (excluding those with a Director of Emergency Medicine Research) published a median of 6 papers (n=1237; IQR 1.5,13; range 0,502) compared to median of 0 from the 47 sites without a head of research (n=193; IQR 0,3; range 0,92). There were 34 sites that didn’t author a publication in the last 5 years.
Funding
The total funding achieved over the last 5 years was approximately $71 million AUD (Figure 4). Of this, $43.1 million was obtained from a national/federal government medical research council and approximately $3-7 million each was obtained from philanthropy, hospital foundations, other foundations, state governments, other federal government grants and from block industry grants.
Major metropolitan and specialist children’s hospitals were the most successful in obtaining grants, small to medium hospitals (metropolitan or regional) the least successful. Four regions performed better than others in obtaining funds per head of population (NZ, QLD, VIC, WA) with the other regions obtaining significantly less. The distribution of funding per site was highly skewed.
The median per site value was $0 (IQR $0,$107.5K; range $0,$21 million). Sixty-six of 112 sites didn’t achieve any funding and a further 20 achieved less than $150K. Seven sites obtained over $500K, 5 over $1 million, and the remaining 12 achieved ≥$1.5 million in grant funding. Sites with a Director of Emergency Medicine Research obtained a median of $105,000 in grants (IQR 5.25,810K), sites without a Director of Emergency Medicine Research obtained a median of $0 in grants (head of research IQR 0,37K; no research lead IQR 0,3K).
Staffing
Eighty-seven sites had emergency physicians conducting research (median 2, IQR 1,4). The median Fulltime Equivalent paid emergency physician research hours was 0.1 (IQR 0,0.25) or 3.8 hours per week. Post-doctoral researchers and other paid researchers worked at 61 sites (median 0, IQR 0,0.5). Most sites had limited resources in terms of personnel and were reliant on volunteer labour (emergency physicians, other ED staff and 173 medical students). Two sites paid multiple ACEM trainees to conduct research and eight others employed 1-2 trainees.
At the 66 sites with heads of research, the 32 Directors of Emergency Medicine Research were paid a median of 10 research hours per week (IQR 5,20; range 0,40). When the head of research didn’t have the Director of Emergency Medicine Research title (33 people) the median paid research time per week was 0 hours per week (IQR 0,5.5; range 0,10).
Culture
Regarding questions about research culture at the EDs, 55% (62/112) thought that emergency medicine research was important to their organisations. Most thought that emergency medicine research was important to their EDs (72%, 81/112). Research leads felt less supported by their fellow emergency physicians with 54% (60/112) giving positive responses and by other ED staff (eg nursing co-workers) with 46% (51/112) positive responses. Most felt unsupported when conducting clinical research with a 70% (78/112) negative response rate. Sectors and regions giving more optimistic responses across all questions included specialist children’s, medium regional and New Zealand hospitals. Those struggling included private and medium metropolitan and South Australian hospitals. Free-text responses from 63 respondents identified 3 major and 3 minor themes. Theme saturation was achieved.
Major themes
- Support
Some felt well supported: “We have been well supported by the hospital”, “We have good support from colleagues for studies and it is a warm and welcoming environment”. Others were supported in theory without practical support: “Organisation expresses commitment but this is not resourced or matched by reality”. Another group felt completely unsupported: “Deprioritised against service provision”, ”no time, support or encouragement locally”.
- Importance of research at the site
There were variable thoughts amongst colleagues regarding the importance of research: “It is important for emergency physicians in this ED to be exposed to research projects”, “some (emergency physicians) do not feel clinical research has a role (for them), I have been asked ‘what’s in it for me?’”, “we have very active nursing research”.
- Research infrastructure as a barrier or enabler
“Support from the Emergency Medicine Foundation research support network has been invaluable”, “poor infrastructure and support processes create active barriers”. When recruiting patients into clinical trials, some had colleagues who actively supported projects, others declined to recruit patients.
Minor themes (practical research training, mentoring and advocacy for research)
Some felt there had been a decline in practical clinical research training since the change to ACEM fellowship training research requirements (allowing course completion instead of manuscript publication or presentation) “we are not developing clinical scientists”, “…created a mindset that there was no benefit to do research” others advocated for mentoring and senior advice for those expressing an interest in clinical research as a career: “…how to set up a research culture….how to actually go about research..”. Finally, there was a need identified for advocacy for the importance of research to enable prioritisation of and resource allocation into research, particularly as many felt there were no resources currently available to them “without resources/funding research isn’t possible”.